SHARP Patient Education and Resource Feedback Form
Please take three minutes to provide feedback on the educational resource you received. Your feedback matters to us!
1.
I am a:
Surgical Patient
Family Member
Caregiver
Other (please specify)
2.
What is your age?
Under 18
18-29
30-49
50-64
65 or older
3.
What is your gender?
Male
Female
4.
What type of surgery will or did you have?
Carpal Tunnel Release
C-section
Dental
Ear, Nose and Throat Procedures (Tonsillectomy and Adenoidectomy)
Gallbladder Removal
General Surgery
Hernia Repair
Ortho/Sports Med (Knee/Shoulder)
Sleep Apnea Implant
Spinal Cord Simulator
Total Joint Replacement
Urology (laser lithotripsy, ureteroscopy, cystoscopy)
Other (please specify)
5.
How helpful were the educational materials you received before surgery?
Extremely helpful
Very helpful
Somewhat helpful
Not so helpful
Not at all helpful
6.
Were the instructions for pre-operative preparation clear and easy to follow?
Yes
Somewhat
No
7.
Did the materials explain what to expect during recovery?
Yes
Somewhat
No
8.
Was the information presented in a way that was easy to understand?
Yes
Somewhat
No
9.
Did you have access to the materials in your preferred language?
Yes
No
If no, what is your preferred language?
10.
When did you receive the education materials?
Well before surgery
A few days before
The day of surgery
After surgery
11.
Was this timing appropriate for you to feel prepared?
Yes
No
If no, please explain
12.
Did you know who to contact if you had questions after reviewing the materials?
Yes
No
13.
How satisfied are you with the surgical education and support you received?
Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied
14.
What did you find most helpful about the educational materials/resources?
15.
What could be improved in the materials or support you received?
